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The Patient's Story

Ms J is a 54-year-old woman with metastatic breast cancer. Her medical oncologist, Dr B, had been providing oncologic care for 2 years; Ms J received multiple courses of chemotherapy and radiation for slowly progressive cancer. One week after starting a new chemotherapy regimen, she developed distended neck veins and had difficulty breathing. Dr B examined her as an outpatient, suspecting obstruction of the superior vena cava. Dr B discussed the range of diagnostic and treatment options with Ms J and her husband. He admitted Ms J to the hospital for a computed tomography (CT) scan and arranged for radiation therapy to begin that evening. Dr B later reviewed the CT scan, which revealed the expected superior vena cava obstruction, along with tumor compression of her trachea. Dr B met with the patient and her husband to discuss the new findings. Given the serious nature of her airway obstruction, Dr B discussed a new set of treatment options should she develop respiratory distress, including intensive care unit (ICU) admission and cardiopulmonary resuscitation (CPR). On the basis of this discussion, Ms J elected to continue the planned radiation therapy, to decline admission to the ICU if her symptoms worsened, and to execute an order to not attempt resuscitation or intubation. Within 12 hours of beginning treatment her symptoms improved; she was discharged home on the third hospital day.

Perspectives

DR B:When the patient had her crisis, we were in a passionate attempt to try more aggressive treatment to palliate her symptoms. It was on a scheduled appointment that I noticed [her] distended neck veins, irritated eyes, and difficulty breathing. She said it all happened in the 24 hours preceding the appointment. We immediately decided that we needed a plan that everybody was comfortable with. First, we had to decide how aggressive to be. I had to make sure that going to the hospital and embarking on emergent treatment was something she thought was appropriate. It was obvious to all of us that the overall journey was nearing its end. This may have been something that would have accelerated her end, and I had to know from her if she wanted to go forward.

Physicians, together with patients and their families, share the burden of decision making throughout the course of a terminal illness. As death nears, such decisions become increasingly difficult as the emotional context becomes magnified. This chapter reviews available evidence and discusses an approach to help physicians provide appropriate care in times of crises near the end of life.